In This Issue

September 2008 | Bradford H. Gray

Relationships between physicians and hospitals are at the heart of many challenges facing health care managers, payers, and policymakers. As medical care is paid for in the United States, hospital executives and physicians live in somewhat different worlds, drawing (with some exceptions) on deliberately separated income streams, as Jeff Goldsmith has put it (personal communication). Nonetheless, many of the current ideas for improving health services, like bundled payments for physicians and hospitals, pay-for-performance, and clinical integration, require cooperation between physicians and hospital administrators. Such cooperation, however, does not come easily or naturally. It is the topic of the first article in this issue of The Milbank Quarterly.

In “Hospital-Physician Collaboration: Landscape of Economic Integration and Impact on Clinical Integration,” Lawton Burns and Ralph Muller survey a large and rapidly evolving array of activities that are changing relationships between hospitals and physicians, including recruitment, risk sharing, and employment. They also analyze the goals that hospitals and physicians bring to their relationship, concluding that any overlap is, at best, partial and does not relate to broader societal goals of reduced cost or improved quality.

Burns and Muller also provide a concise review of the research literature on the impact of the various models of integration on cost efficiency, clinical integration, and quality outcomes. Because so many different models and possible effects are involved, the results defy brief summarization here, but Burns and Muller’s overall conclusion is that the effects generally appear to be weak and inconsistent. After discussing the possible reasons for this, they conclude by analyzing several factors that facilitate or hinder the economic and clinical integration of hospitals and physicians.

The next article in this issue, “Getting Real Performance Out of Pay-for-Performance,” by Sean Nicholson, Mark Pauly, Anita Ya Jung Wu, James Murray, Steven Teutsch, and Marc Berger, is a theoretical analysis of a payment strategy that has gained popularity in recent years. They argue that pay-for-performance based on process-of-care measures can affect outcomes (the ultimate goal) only insofar as the rewarded processes reliably lead to better outcomes and that the processes now being rewarded are only weakly linked to better outcomes. This limits the value of pay-for-performance as a health improvement strategy.

Basing pay-for-performance programs on outcomes would seem to avoid this limitation, so Nicholson and his colleagues analyze the conditions under which basing rewards on outcomes-based measures would be a sound strategy. They conclude that such an approach would work best when purchasers know less than providers do about which processes produce health improvements and when purchasers are able to risk-adjust measures of patients’ health status. Conversely, they argue, outcomes-based pay-for-performance approaches would be unnecessary if definitive information were available about what they call the health production function or if provider-specific, severity-adjusted outcome data were available and actually used by patients to select service providers. Under the former condition, well-designed fee-for-service payments would work, and under the latter conditions, patients’ choice of providers would serve the same purpose as pay-for-performance does.

The next article in this issue is concerned with the health care of uninsured people who do not have access to employer-sponsored insurance and who are not eligible for public programs such as Medicaid. In “Local Access to Care Programs (LACPs): New Developments in the Access to Care for the Uninsured,” Lynn Blewett, Jeanette Ziegenfuss, and Michael Davern examine programs that have been developed—largely independently by cities and counties across the country—to facilitate access to medical care for uninsured people. These programs do not involve insurance and so are not subject to the service entitlements and regulatory oversight that accompanies insurance. But they provide more structure than is offered by establishing facilities at which uninsured people can seek care.

These local access to care programs (LACPs), as the authors term them, include an enrollment mechanism, nominal enrollment fees (though not actuarially based, as insurance charges are), and networks of providers that commit to offering a specified amount of services, either at no charge or for highly discounted fees. Using a variety of methods, Blewett, Ziegenfuss, and Davern identified forty-seven LACPs in twenty-seven states, serving an estimated 640,000 enrollees. They describe four different types of arrangements for financing and organization, arguing that greater awareness of these programs among researchers is the first step to understanding their operation and impact. The stability of these programs and the difference they make for their enrollees and for local service providers are not yet understood.

Epidemiologists have taught us that many of the most important determinants of population health—matters pertaining to poverty, education, working conditions, and neighborhoods—lie beyond the reach of the health care system. However, the public and the media tend to think of personal health behavior and access to medical care as the primary factors affecting health. The next article in this issue is concerned with what can be done to change this view. In “Message Design Strategies to Raise Public Awareness of Social Determinants of Health and Population Health Disparities,” Jeff Niederdeppe, Q. Lisa Bu, Porismita Borah, David Kindig, and Stephanie Robert link the field of communications science with the topic of population health.

The authors summarize the available evidence regarding three communication strategies—message framing, narratives, and visual imagery—and consider how they could be used to increase public awareness of the social determinants of health and social disparities in health status. The authors identify those factors that must be overcome in order to stimulate action by raising public awareness. Unfortunately, the most easily reached audience (the best educated) is not the population that could be most readily mobilized by appeals to self-interest.

Niederdeppe and his colleagues also discuss pitfalls that may arise when various message strategies are used, including the danger that the strategy itself may distract audiences from the central message or stimulate counterproductive emotional reactions such as anger and guilt. After acknowledging the limits of the evidence they have summarized regarding how to communicate messages pertaining to population health, the authors conclude by identifying promising areas for future research.

Bradford H. Gray
Editor, The Milbank Quarterly

Author(s): Bradford H. Gray

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Volume 86, Issue 3 (pages 371–373)
DOI: 10.1111/j.1468-0009.2008.00526.x
Published in 2008